A 52-year-old female presents to the Sydney heel pain clinic, Miranda, complaining of plantar fasciitis in both feet. She explains to the podiatrist that her condition came on approximately 2 weeks ago, following extended use of thongs and Sandals. During the Christmas holidays, she went with her family to a holiday home and spent most days walking on the beach in her bare feet. She recalls feeling the early signs of plantar fasciitis as she walked around the holiday home on the hard tiled floors. She describes the feeling of a stone bruise under the base of her heel and the occasional shooting pain which would stop her from walking. The pain from the plantar fasciitis is more severe in the left foot compared to the right foot but both feet are extremely tender first thing in the morning as the patient puts her feet to the ground. This lady Works in the Sydney CBD and spends most of her working day seated at an office desk. She also describes a relatively sedentary lifestyle and rarely walks for extended periods and she did over the Christmas holidays. She has a short walk from the train station to the office each day but drives from her house to the train station. She explains to the sports podiatrist, that as her plantar fasciitis developed she also felt some twinges in her Achilles tendons. She is otherwise healthy and takes no medications. She does not have diabetes or any chronic medical conditions. She has never suffered with plantar fasciitis before, but she does recall some mild arch pain throughout the summer period last year. Following the onset of this heel pain, she decided to give herself some gentle foot massage. She also rolled her foot on a frozen water bottle in order to relieve the pain. After returning to Sydney from her holiday home, she purchased a pair of running shoes and has been using these as much as possible. She does report to the podiatrist that she feels less pain in the trainers, but that her plantar fasciitis is persistent. She is aware of the heel pain every day of the week in particular, every morning. Towards the end of the day she does report an increase in pain combined with a stabbing sensation. At this stage she has not sought any treatment for her plantar fasciitis but has carried out extensive research and has become informed via online reading.
This patient presented with symptoms consistent with plantar fasciitis, and her suspicions were confirmed following a physical assessment. The sports podiatrist applied gentle pressure along the mid fibres of the plantar fascia through the arch of the foot and around the base of the heel. There was no pain along the middle of this patients feet, but there was significant pain on palpation of the plantar fasciitis at the base of the heels. The patient was unable to perform a single leg heel raise without reporting pain through the bottom of her heel. She was however able to perform heel raises using both feet simultaneously. During her single leg heel raise there was also pain through the Achilles tendon on the right leg. Mild compression and palpation of both Achilles tendons elicited pain consistent with Achilles tendonitis. The patient was informed that she has two different conditions affecting her feet. Plantar fasciitis and Achilles tendonitis in her right leg
In order to determine the cause of this patients’ plantar fasciitis and Achilles tendonitis, the sports podiatrist carried out throughout biomechanical assessment. Markers were placed on the back of the heel and the Achilles tendon and the patient was asked to walk on the treadmill while the sports podiatrist observed. Data was collected using an iPad and digital software. The patients gait cycle was captured and re played in slow motion. The podiatrist was able to observe a pes cavus foot type with a very high arch and minimal subtalar joint pronation. Both feet were marginally externally rotated. There did not appear to be any leg length discrepancy or early he left due to tight calf muscles. There appeared to be appropriate first ray joint function and re-supination through the first toe. Towards the end of the assessment, the patient was unable to walk without limping or holding onto the handrails due to the pain from her plantar fasciitis.
It was explained to the patient that the likely cause of her plantar fasciitis was a lack of support underneath her high arches, while using very flat thongs on hard flat surfaces, and that she would have strained her feet while walking on the sand so much. Her foot type is one that receives increased pressure under the heel and the ball of the foot but virtually no contact underneath the arches. This lack of contact creates excessive strain through the arch of the foot, mainly through the plantar fascia. The prolonged strain leads to plantar fasciitis as the soft tissue pulls away at the base of the heel. Because this patient had only been suffering for a short period of time the podiatrist explained that she would try to treat her plantar fasciitis without the use of prescription orthotics. To this end, it was decided to support the patients feet with a rigid sports tape and firm running shoes. This patient was also treated on the spot with 2000 reps of Shock wave therapy. She was instructed to return to the clinic once a week for at least 3 weeks for repeat sessions of shock wave therapy. The recovery of this patient’s plantar fasciitis was not limited by calf muscle tightness. Therefore she was not required to perform regular calf stretching exercises.
After 3 weeks of rehabilitation and weekly sessions of Shock wave therapy, this patient reported approximately 50% Improvement in her plantar fasciitis. She informed the sports podiatrist that with the sports tape around her feet she feels much more secure and her feet feel stronger. Her response to treatment was typical of patients with plantar fasciitis, and she reported that there was still pain in the ball of her heel when she stepped out of bed in a morning. The podiatrist reassured the patient that her progress was normal and that conditions such as plantar fasciitis and Achilles tendonitis do not heal quickly due to impaired blood supply. The treatment plan was not changed and further sessions of shock wave therapy were put in place. In addition to the current treatment plan the patient was advised to apply soft ice packs to the base of her heel and around the Achilles tendons daily, for at least 30 minutes. With each week that passed, the patient reported slow but definite improvement in her plantar fasciitis and Achilles tendon pain.
After 6 weeks and 6 sessions of shockwave therapy the patient reported further improvement in her plantar fasciitis and Achilles tendonitis. The podiatrist informed the patient that her shock wave therapy sessions would now stop and the healing would continue. She was advised to continue strapping her feet and using running shoes as much as possible. Once in the office, she was informed that switching from her running shoes to her office shoes would be fine, as she spends most of her days seated. At this 6 week appointment, the patient reported approximately 80% improvement in both of her conditions. She was happy to know that no further appointments would be necessary and that even without further shock wave therapy sessions the healing would continue as a result of improved circulation and revascularisation. The patient was informed to contact the clinic in a further four weeks if her plantar fasciitis had not resolved and if there was residual pain from the Achilles tendon or plantar fascia. No further appointments were recorded.
Please note that the information contained in this case study is specific to one particular patient and is not general advice. If you suffer with Achilles tendonitis or plantar fasciitis you should seek the help of a suitably qualified sports podiatrist or other qualified health care practitioner.
Patient: Not named
Podiatrist: Fatemeh Abdi